| Nutrition Care Process and Documentation |
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- Purpose
- To ensure proper administration of Nutrition care.
- To provide standards when to conduct routine Nutrition Care Process
- Definitions
- Nutrition Care Process - a method for Clinical Dietitians applying standardized process for providing care and standardized language in making decisions and provide high quality nutrition care.
- Nutritional Assessment – to identify patient’s nutritional problems and high risk patients who need special attention as a basis for nutritional care plan. It includes collection and analysis of anthropometric, biochemical, clinical, dietary, and psychosocial data as well as consideration of the planned therapeutic management
- Policy Statements
3.1 Clinical Dietitians shall conduct daily ward rounds of their assigned nursing units.
- 3.2 Clinical Dietitians shall provide diet counseling and monitor patient’s tolerance on the recommended diet
Procedures
- All adults and pediatric patients should have nutrition screening to be accomplished by Nursing Unit via electronic system Nursing Admission access.
- To check nutrition referral through electronic system to prioritize patients who are referred for further dietary assessment and those who are nutritionally at risk. (Refer to DPP 8010-01-01-09)
- To provide routine ward rounds to those critically ill patients on Tube feeding, in ICU –intensive care unit, with low serum albumin, parenteral nutrition.
- During ward rounds, the Clinical Dietitian should perform First Nutritional assessment 24-48 hours. To review on the 2nd – 3rd day, 5th, 7th day after the first initial assessment.
- Nutritional Re-assessment should be done for those re-admitted and long term patients. On the 3rd week after the initial nutritional assessment should conduct nutritional re-assessment for short term patients. Every 2 months for those stable long term patients.
- Assessment of the patient’s nutritional status shall be based on anthropometric data, biochemical investigation, clinical, diet history and psychosocial data.
- Nutrition history including food allergies and medication.
- Appropriate endorsement of patient’s dietary management of Clinical Dietitian (endorser) to the Clinical Dietitian (receiver), once the patient transfers to another ward.
- The Clinical Dietitian shall join the medical team grand rounds including the Discharge Planning
- Clinical Dietitian shall provide individualized diet counseling with written instructions /diet guides.
- Whenever possible family members should be included in the development of nutrition care plan and education regarding patient’s recommended diet.
- The Clinical Dietitian shall join the medical team grand rounds including the Discharge Planning meeting.
- All Clinical Dietitians shall document relevant information regarding patient’s adherence to the prescribed diet via electronic system.
- Official documentation via electronic system should follow the ADIME format (Nutritional Assessment, Diagnosis, Intervention, Monitoring, Evaluation) the latest Nutrition Care Process format of American Dietetic Association.
- Recommended diet based on nutritional assessment shall be coordinated with the attending consultant and nurse.
- Equipment / Forms
Computer for electronic documentation - QuadraMed
- Related References
American Dietetic Association www.eatright.org
- Appendices
DPP 8010-01-01-09
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